Name & Address of Agency




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_______________________________________________

Name & Address of Agency

TO: DEPARTMENT OF FINANCIAL SERVICES ________________

DATE
CASH REFUND REQUIRED

Restoration to current year appropriation
Transmittal Of:

NOTICE OF REFUND REQUIRED ON ACCOUNT OF:


( ) Disbursement made during the current fiscal year in the amount of $

for restoration to:






SAMAS ACCOUNT CODE

























































































ACCOUNT NAME:

Originally disbursed by warrant number dated _________________

Original Object Classification Code * or refer to


Letter of Authorization # dated

*(If Object Code 2600 or 1100)

Name of Employee

Social Security #


I hereby certify that to the best of my knowledge and belief the request for restoration to the above

named account (s) is true and correct and complies with all provisions of the Florida Statues,

applicable opinions of the Attorney General and rules and regulations of the Dept. of Financial Services..

Authorized Signature


_________________

Prepared By Telephone number



CBA-22

DFS-A2-1896


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